Ba sic Asse ssme nt: a nd Alp ha b e t so up ! Yo u c a n use fo - PowerPoint PPT Presentation

Ba sic Asse ssme nt: a nd Alp ha b e t so up ! Yo u c a n use fo r a ll p a tie nts! T his to p ic will re view the nurse s a sse ssme nt impo r tanc e in the a sse ssme nt o f a ll typ e s o f p a tie nts that p re se nt to E D a nd a lso c a n b e use d o n inp atients.

L e t’ s g e t Sta rte d  Wha t d o the a c ro nyms me a n a nd d o the y he lp !!  We ll Ye s the y d o  F o llow up e ve r y p atie nt eve r y time a nd yo u wo n’ t miss a thing!  L e t’ s sta rt :

No w A,B,C, D ( sing a lo ng )  C AND A to ge the r : Ble e d ing( c irc ulatio n Obvious b le eding) Sto p a nd c o ntro l  Airway a nd C sp ine : L o o k, into the a irwa y, listen fo r no ise s, b re a thing, F e e l fo r a ir mo vement: Inte r vene : Ho w?  Re p o sition, Suc tio n, Ap p ly O2, Sto p a nd Ba g: Is tha t e a sy?  Ja w thrust a nd E C T e c hnique

L e t’ s d e sc rib e the BVM

Hig h F lo w Oxyg e n T he ra p y

Ne o na ta l to Ad ult

Are we b re a thing ye t? ?  F o r the p a tient  Or p a tie nt o n the ir o wn  Ho w e ffe c tive a re we o r the y  Ra te a nd d e e p o f re sp ir a tio ns  E ffe c tive ne ss: Co lor improving  Are we tiring o r is the p a tie nt tiring?

B: Bre a thing is it e ffe c tive ? ?  Co lo r  Ale rt  Ra te a nd d e p th  Is o ur a d junc t wo rking  Ca n we mo ve o n?

C: Circ ula tio n  Ble e d ing?  Co lo r  Ce ntra l a nd p e rip he ral p ulse s  If we a k o r d iffe re nt why?  Do we ne e d b lo o d , fluid s,Oxyge n, More c a rd iac o utput  Wha t is the p a tie nts c hie f c o mplaint?

D: Disa b ility  Ne uro sta tus  Me ntatio n: BS  Pup ils  GCS Sc o re

E : E xp o sure a nd E nviro nme nta l Co ntro l Ge t the pa tie nts c lo the s o ff, pla c e in g o wn All pa tie nts g e t na ke d!!! Co ve r, pro te c t mo de sty a nd q uic k a sse ss the skin

F : F ull se t o f Vita l Sig ns  T his inc lude s T e mpe ra ture  He a rt ra te  Re spira to ry ra te  Blo o d pre ssure :  Ho w to ta ke b lo o d pre ssure : T his is whe n I a usc ulta te o ne if the pa tie nt is sic k”

G: Give c o mfo rt me a sure a nd Ge t Mo nito ring d e vic e s  Co mfo rt: Pa in, No n p ha rma c o logic al mea sure s  Pa in me d ic a tio ns  All mo nitors o n, re a sse ss Vital signs  Blo o d suga r  L : IV,labsif no t d o ne  M: Mo nito r  Oxyge na tio n: Re a sse ss, Sa tura tio n wo rk o f b re a thing, Ca p no gra phy? Do we ne e d it?  De p e nd s o n p a tie nt

H: Histo ry  Why a re the he re  Wha t is c hie f c o mp laint to d a y  Is it re la te d to p rio r Histo r y: T ha nks to e le c tro nic he alth re c ords we c a n usua lly find so me info rma tion  F ind ings to c a use a la rm: Ale rt p rovide r  Me dic atio ns: Have the y b e e n ta king the m a nd if so whe n,wha t a nd ho w muc h  Dia gno stic s : Wha t d o yo u a ntic ipa te will b e ne e d e d ?  He lp yo ur p ro vid er o ut a s yo u se e the p a tie nt first a nd la st in mo st c a se s.

Insp e c t a nd re a sse ss  He a d to to e a sse ssme nt a nd d o n’ t fo rge t the b a c k sid e  We might no tic e skin c olo r c ha nge s, sta rt o f d e c ub iti's ulc e r, unke mpt hygie ne

With e a c h p a tie nt e a c h time We will ha ve g o o d o ut c o me s  Dilige nt b y b e d sid e c are give rs save s p a tients a nd ho p e fully p reve nts d e c line .

Re fe re nc e s  E NA.o rg  Ame ric a n Assoc iatio n o f Critic al c a re : AACN.o rg  E M ra p